Autosomal dominant polycystic kidney disease (ADPKD) is an exceptionally common hereditary nephropathology with an incidence of about 1 in 800 live births. The disease is progressive, phenotypically characterized by bilaterally enlarged polycystic kidneys, and typically resulting in end-stage renal disease (ESRD) by the age of 65 years. The more common complications include hypertension, macrohaematuria, urinary-tract infection, cardiac-valve abnormalities, and hernia of the anterior abdominal wall. Cyst formation is also commonly observed in the liver, although the occurrence is not associated with functional impairment of the organ. Although not as frequently reported, additional extrarenal manifestations include pancreatic cysts, connective tissue abnormalities, and cerebral-artery aneurysms.
The typical age of onset is in middle life, but the range is from infancy to 80 years. The clinical presentation of ADPKD differs between and within families as partly explained by the genetically heterogeneous nature of the disorder. Mutations in two genes, PKD-1 and PKD-2, account for nearly all cases of ADPKD (e.g., for reviews, see Arnaout, 2001, Annu Rev. Med. 52:93-123; Koptides and Deltas, 2000, Hum. Genet. 107:115-126). PKD-1 and PKD-2 encode integral membrane proteins whose functions have not been fully elucidated. The major gene responsible for ADPKD, PKD-1, has been fully characterized and shown to encode an integral membrane protein, polycystin 1, which is thought to be involved in cell-cell and cell-matrix interaction. PKD-2 gene encodes polycystin-2 which is a predicted integral membrane protein with non-selective cation channel activity. Based on sequence homology with the alpha 1 subunit component of voltage-activated calcium channels, it has been postulated that polycystin-2 may play a role in ion channeling. The C-terminal cytoplasmic tails of polycystin-1 and polycystin-2 have been shown to interact using in vitro binding assays and in a directed two-hybrid interaction. The interaction occurs via a coiled-coil domain in PKD-1 and a region near R872 in PKD-2. Although the biological relevance of the interaction between the polycystins is not yet understood, it does suggest that PKD-1 and PKD-2 are likely to function along a common pathway.
Both ADPKD type 1 and type 2 share the entire range of renal and extrarenal manifestations, but type 2 appears to have a delayed onset relative to type 1. The common phenotypic complications observed for ADPKD including hypertension, hematuria, and urinary tract infection seem to be clinically milder in type 2 patients. The median age at death or onset of ESRD has been reported as 53 years in individuals with PKD-1 and 69 years in those with PKD-2. Women have been reported to have a significantly longer median survival of 71 years than men (67 years). No sex influence is apparent in PKD-1. Mutations in the PKD-1 gene are the cause of ADPKD in approximately 85% of the cases tested, while those in PKD-2 account for 15%. Although a small subset of families with ADPKD fail to demonstrate genetic linkage to either PKD-1 or PKD-2, raising the possibility of a third gene for ADPKD, the existence of a third disease-associated locus has been strongly challenged.
Despite the discovery of strong links between genetic alterations in PKD genes and the onset of ADPKD, the development of a genetic testing method for ADPKD predisposition for routine clinical use has been hindered by several technical obstacles.
One serious obstacle for developing a DNA-based testing method for ADPKD is that sequences related to the PKD transcript, for example, PKD-1, are duplicated at least three times on chromosome 16 proximal to the PKD-1 locus, forming PKD-1 homologues. Another obstacle is that the PKD-1 genomic interval also contains repeat elements that are present in other genomic regions. In addition, the sequences of PKD genes are extremely GC rich and a large number (15,816 bp) of nucleotides need to be analyzed for a thorough evaluation.
There is a need for the identification of segments of these sequences that are unique to the expressed PKD genes and not are present in the duplicated homologous sequences. There is also a need for developing a sensitive and specific genetic testing method for mutational analysis of PKD genes. The development of such genetic testing method would facilitate the diagnosis and management of ADPKD.